Case Report
Peritonsillar swelling is not always quinsy
Mohamad I, Yaroko AA
Mohamad I, Yaroko, AA. Peritonsillar swelling is not always quinsy. Malaysian Family Physician 2013;8(2): 53-5
Keywords:
quinsy, peritonsillar
abscess, cellulitis,
needle aspiration
Authors:
Irfan Mohamad
MD (USM), M Med (ORL-HNS)
(Corresponding author)
Department of
Otorhinolaryngology-Head
& Neck Surgery,
School of Medical Sciences,
Universiti Sains Malaysia
Health Campus,
16150 Kota Bharu,
Kelantan, Malaysia.
Tel: +6097676420
Fax: +6097676424
Email: irfan@kb.usm.my
Ali Ango Yaroko,
MBBS, M.Med (ORL-HNS)
Department of
Otorhinolaryngology-Head
& Neck Surgery, School of
Medical Sciences, Universiti
Sains Malaysia Health
Campus, Kelantan,
Malaysia
Email:aliango2002@yahoo.
com
Abstract
Quinsy is a common encounter in family physician practice. It is defined as a collection of purulent
material in the peritonsillar space, giving appearance of unilateral palatal bulge. Presenting
symptoms include trismus, muffled voice, odynophagia, and ipsilateral otalgia. When the
diagnostic needle aspiration reveals no pus, the diagnosis is changed into peritonsillar cellulitis or
also known as perintonsillitis. Peritonsillitis is sufficiently treated with antibiotics unlike a quinsy
which warrants surgical incision and drainage.
Introduction revealed enlargement of the left tonsil with
inflamed supratonsillar tissues pushing the
Acute tonsillitis is a disease in children, edematous uvula towards the right side (Figure
whereas peritonsillar cellulitis and abscess are 1). However, the right tonsil was normal. The
known to affect young adults. Peritonsillar left level II cervical lymph nodes were palpable
cellulitis is considered as a transition phase and tender. Nose and ear examination was
of the peritonsillar inflammatory process normal. Blood examination revealed a raised
becoming an abscess or quinsy. It may or may white cell count of 16.86 g/dL, whereas other
blood parameters were normal.
not be related with previous or concurrent
tonsillitis. Current review confirms that
peritonsillar infection begins with Weber’s When quinsy was diagnosed, the patient was
gland, a group of 20-25 mucous salivary glands admitted for further evaluation and treatment.
located in the space just superior to the tonsil Soft peritonsillar swelling was aspirated
in the soft palate.1 Peritonsillar cellulitis is the according to the conventional management
manifestation of inflamed Weber’s gland in the for quinsy. Aspiration was attempted in few
soft palate. sites at the most prominent bulge (Figure 2).
However, no purulent material was syringed
out. The diagnosis was changed to peritonsillar
Case Summary cellulitis. Intravenous penicillin (2.4 mU
loading dose, followed by 1.2 mU six-hourly)
A 29-year-old Malay man with no known and analgesics (oral paracetamol 1 g eight-
medical illness presented with 6 days’ history hourly) were initiated. The patient was able
of fever, sore throat, and odynophagia to solid to take the dose orally on the later part of the
food. His mouth opening was limited, which day. There was no more trismus. On the 3rd
was associated with ‘hot potato voice’ and neck day of admission, the patient was comfortable
pain on the left side. This was the first episode. and his oral intake returned to normal. He was
There was no history of nasal and ear symptoms. discharged from the hospital, with the advice
to complete the antibiotic treatment, which
His vital signs were normal, with blood pressure included oral penicillin 250 mg six-hourly for
of 130/84 mm Hg, pulse of 96 beats/min, 1 week.
and temperature of 37.9°C. Oral examination
Malaysian Family Physician 2013; Volume 8, Number 2 53
 Case Report
Figure 1.
Inflamed left supratonsillar tissue and oedematous uvula
Figure 2.
Inflamed left supratonsillar area with puncture sites seen
(arrows)
*Verbal consent has been obtained for the figures.
Discussion
As the clinical features of quinsy and
peritonsillar cellulitis are similar, needle
aspiration of the peritonsillar swelling confirms
the diagnosis of quinsy or cellulitis. Guarded
needle aspiration was used to avoid over-
penetration into the soft palate. The presence of
pus confirms the diagnosis of quinsy. A proper
incision is needed at the most prominent bulge,
which should be opened with forceps to drain
out the pus. However, if no pus is aspirated,
the diagnosis of peritonsillar cellulitis or
peritonsillitis is established. Family physicians
with appropriate training and experience can
diagnose and treat majority of patients with this
54 Malaysian Family Physician 2013; Volume 8, Number 2
condition. When complications or questions
arise during treatment, an otolaryngologist
should be consulted.2
In this patient, the aspiration of purulent
material was negative. As expected, the clinical
symptoms improved after the procedure. This
is attributed to release of built-in tension and
pressure (due to soft tissue oedema) in the
closed peritonsillar space using the method of
needle aspiration. However, in either case of
quinsy or cellulitis, antibiotics are started to
target gram-positive bacteria, most commonly
Streptococcus.3 Penicillin is the antibiotic of
choice except in penicillin-allergic or penicillin-
resistant patients. Besides intravenous
benzylpenicillin, co-amoxiclav can be used
as the first-line therapy.4 ‘Hot tonsillectomy’
(tonsillectomy during the attack of quinsy) is
previously considered as the treatment during
the quinsy episode. However, current review
shows that it was not the treatment of choice
in more than 80% of peritonsillar infection
cases.5 The popularity decreased because it was
associated with increased risk of bleeding and
it was not cost-effective compared to elective
tonsillectomy.
In recurrent cases of peritonsillar infection,
tonsillectomy is indicated. If the patient
was diagnosed and treated at an early stage
(cellulitis instead of abscess), there would have
been slightly less probability of using a surgical
procedure for treatment.4 The recurrence of
peritonsillar infection is possible even after
tonsillectomy, considering the pathophysiology
of the disease; however, it is rare.6
Conclusion
The clinical presentations of quinsy and
peritonsillar space cellulitis are the same. The
only confirmatory step is guarded needle
aspiration of the swelling. Pus aspirate warrants
incision and drainage, whereby cellulitis can be
effectively treated with antibiotics alone.
 Case Report

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